Provider Demographics
NPI:1811952385
Name:CLARK, DAVID B (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9051 WATSON RD
Mailing Address - Street 2:#263
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-2240
Mailing Address - Country:US
Mailing Address - Phone:314-667-5397
Mailing Address - Fax:314-627-0767
Practice Address - Street 1:9051 WATSON RD
Practice Address - Street 2:#263
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-2240
Practice Address - Country:US
Practice Address - Phone:314-667-5397
Practice Address - Fax:314-627-0767
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003015259208D00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2002364OtherUNITED HEALTHCARE
MO145402OtherHEALTHLINK
MO127254OtherBLUE CHOICE
MO127254OtherBLUE SHIELD
MO208429605Medicaid
MO127254OtherBLUE SHIELD
MO904270635Medicare PIN
MO2002364OtherUNITED HEALTHCARE
MO208429605Medicaid
MOP00104746Medicare PIN